Download Notice of Privacy Practice

Centered In Wellness Notice of Privacy Practice
This notice describes how medical information about you may be used and disclosed, and how you
can access this information. Please read carefully.
As medical professionals, we understand that information about you and your health is sensitive and
personal. This health information, which includes your symptoms, test results, diagnosis and treatment,
is protected by law. It will not be disclosed to others unless you tell us to do so, or unless we are
required to do so by law.
This notice is published to clarify the reasons for which we might relay information about you to
another provider for treatment, payment, or Health Operations.

Treatment: Information about you will be recorded by a nurse, a physician, or other member of the
treatment team for use in diagnosing and treating your illness. We may also provide this
information to others providing you care.

Payment: We request payment from your health insurer. Health plans need information about your
medical care.

Healthcare Operations: Your medical records are used to assess quality of care to improve services.
They may also be used to assess the qualifications and performance of your health care providers.
You may be contacted about other health-related issues or alternative treatments.
Your Health Information Rights
The health and billing records that we create are the property of Centered In Wellness.
The health information in these records, however, belongs to you. You have the right to:
· Receive and ask questions about this Notice
· Ask us to restrict certain uses and disclosures. We are not required to grant the request, but we will
comply with any request granted.
· Request and receive from us a copy of your health information. You must make this request in
writing. You may request changes to your health information, or write a statement of disagreement
if your request is denied. It will be stored with your medical record and be included in any records
released.
· Request a list of any disclosures which have been made of your health records every 12 months.
There is no charge for this service.
· Cancel prior authorizations to use or disclose health information by giving us a written revocation.
This will not affect information which has already been released. Authorizations used to obtain
insurance generally cannot be cancelled.
For help with these rights during normal business hours, contact: Maryann Nakamura
Our Responsibilities
We are required to:
· Keep your protected health information private
· Provide this notice
· Follow the terms of this notice
We may change our practices, and will update this notice if that occurs. If you believe that your privacy
has been violated, you may send a written complaint to us, and to the U.S. Secretary of Health and
Human Services.
Uses of Your Health Information Without Your Permission
· Medical Research which is approved and has its own safety precautions
· Funeral Directors/Coroners consistent with their duties
· Organ Procurement Organizations
· FDA relating to problems with foods and supplements
· Public Health and Safety Purposes as required by law to prevent threats to the health and safety of
the public, to control disease, injury, disability or to report vital statistics such and birth and death
· Reportage of suspected child abuse
· Law Enforcement such as subpoenas, court orders, or other legal processes
· Health and Safety Oversight, as in the Department of Health
· Disaster Relief Purposes, such as reporting your condition to family members
· Work-Related Conditions that could affect employee health
· Judicial and Administrative Proceedings, national security, military missions
Uses not in this notice will be made only as allowed or required by law, or with your written
authorization
Effective Date of this notice: October 7, 2014
NOTICE OF PRIVACY PRACTICES – ACKNOWLEDGEMENT
We keep a record of the health care services we provide. You may ask to see or to copy that record. You
may ask to correct that record. We will not disclose your record to others unless you direct us to do so,
or unless the law compels us to do so. You may see your record or get more information about it by
contacting Maryann Nakamura.
Our Notice of Privacy Practices describes in more detail how your health information may be used and
disclosed. There are two other areas which we would like to discuss with you.
We bill your insurance as a courtesy to you. You are responsible for understanding the terms of your
insurance policy and the coverage that it provides, as well as for payment to us for services not covered
by your insurance. Once you accept services from us, we expect to be paid for these services.
Should it be necessary to cancel or reschedule appointments, we respectfully ask that you give 24 hours
notice of the change you wish to make. We may charge a fee of $50.00 for skipped appointments for
which we do not receive notification.
By my signature below, I acknowledge receipt of these notices from Centered In Wellness.
_____________________________________________________________________________________
Parent, Guardian, Patient signature
Date
_____________________________________________________________________________________
Printed Name Relationship
This form will be retained in your medical file.